Provider Demographics
NPI:1982777959
Name:MARINA DENTAL PC
Entity Type:Organization
Organization Name:MARINA DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PODLUBNY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-234-2244
Mailing Address - Street 1:3768 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1548
Mailing Address - Country:US
Mailing Address - Phone:212-234-2244
Mailing Address - Fax:212-281-3789
Practice Address - Street 1:3768 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1548
Practice Address - Country:US
Practice Address - Phone:212-234-2244
Practice Address - Fax:212-281-3789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0474431261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01804833Medicaid